This webinar offers a chance to explore the challenges and opportunities of the Safety-II approach with Mark Sujan, co-author of the BMJ Quality and Safety article ‘The problem with making Safety-II work in healthcare.’
In 2020 Q’s ‘Organisational Resilience & Safety-II’ Special Interest Group (SIG) ran workshops to share adaptations being made to address the emerging COVID-19 crisis. Many solutions were shared but significant challenges were identified. In this webinar we will build on the insights found and explore the arguments in the recent BMJ Quality and Safety article, ‘The pro
Safety-II is rapidly capturing the attention of the improvement world. However, there is very little guidance on how to apply it in practice. THIS Institute at the University of Cambridge have funded a study to explore how Safety-II (or Resilient Health Care) is being translated into healthcare policy and practice.
Ruth is looking for people to take part in a one-off interview. She wants to speak to people who:
work within the NHS to improve patient safety (whatever your role!)
have or are applying Safety-II principles to improve safety in either maternity, A&E, ICU or a
After two years with virtual workshops due to the Covid-19 pandemic, we are pleased to announce that the fifth International Workshop on Safety-II in Practice will be organised on site in Edinburgh, Scotland on September 7-9, 2022. The Workshop is organised by FRAMsynt. The workshop will begin with an optional half-day tutorial on Safety-II in Practice in the afternoon of September 7 (1330-1730 BST), and continue with two days of meetings and discussions from September 8 (0830-1700 BST) to September 9 (0830-1500 BST). There will be a walking tour of Edinburgh old town (hosted by Steven Shorroc
This article from Adrian Plunkett and Emma Plunkett, discusses some of the theoretical limitations of the prevailing approach to patient safety and introduce emerging, complementary approaches in this field of practice. Safety-II and resilience engineering represent a new paradigm of safety, characterized by focusing on the entirety of work, with a system-wide lens, rather than single incidents of failure. More overtly positive approaches are available, specifically focusing on success—both outstanding success and everyday success—including exnovation, appreciative inquiry, learning from excel
‘Work as done’
Because healthcare is constantly evolving and complex, by looking more closely at everyday work and finding out what actually happens, it allows an understanding of what it is, that frontline clinicians do to ensure successful outcomes. This is termed as looking at 'work as done' and informs us about the nuances, the adjustments, the compromises, the workarounds, the actions and the decision making that is taken to meet the needs of the patients they are caring for.
‘Work as done’ is a combination of expertise, clinical decisions, experience and tacit knowledge. It is
A year ago, you implemented a new approach to auditing at Barnsley. Can you tell us what prompted it?
In healthcare, we tend to measure safety by looking at negatives. The number of falls, the number of category 2 pressure ulcers, the number of adverse events etc. Our whole system is built on it, from local auditing and Datix reporting, to CQC inspections. But counting the number of pressure ulcers for example, doesn’t really tell you about the standards of pressure ulcer care.
I wanted to look at things differently; to focus more on the interventions and good practice that helps ke
Learning from Excellence (LfE) is a system for capturing examples of good practice in healthcare as a complementary approach to traditional incident reporting.
The LfE philosophy proposes that learning from what works well in a system enables improvements in the quality and safety of the work, and the morale of staff performing it.
LfE systems comprise simple reporting forms for peer-to-peer positive feedback with sharing of examples to enable wider learning.
LfE reporting identifies excellence and learning opportunities in both process and outcome.
Having recently read a helpful and thought provoking summary on the varieties of human work by Steven Shorrock, I wanted to reflect on how the concepts he discussed apply to healthcare. I also wanted to look at how they might inform the thinking and actions of those working in patient safety roles in organisations where they do not have regular and direct contact with frontline staff.
Shorrock discussed the four varieties of human work: work-as-imagined, work-as-prescribed, work-as-disclosed and work-as-done. All are instantly relatable to those who have worked in the NHS.
The Flight Safety Foundation goal with this Seminar is to promote further globally the practical implementation of the concepts of system safety thinking, resilience and Safety II. There will be two sessions, one for each day, that will consist of briefings and a Q&A panel afterwards.
The following themes are suggested for briefings and discussions for the Seminar
1.The limits of only learning from unwanted events.
2. Individuals’ natural versus organisations’ consciously pursued resilience.
3. How the ancient evolutionary individual instincts for psychological safety affect
As in previous years, it is certain that under-reporting is significant. Reporting rates in some of the higher usage Trusts/Health Boards vary twentyfold. Given the cultural, resource and procedural similarities of these organisations, it is highly unlikely that the error and mishap rate varies by anything like this much, so reporting rates are likely to play a large part. One area where this is likely to have greatest impact is in the reporting of near misses, the most fertile learning area.
The leading causes of transfusion-related incidents are, again this year, ‘human factors’ related